Adjuvant FOLFIRINOX in Patients with Resectable Pancreatic Cancer Is Effective but Rarely Feasible in Real Life: Is Neoadjuvant FOLFIRINOX a Better Option?

BACKGROUND: The recommended treatment for resectable pancreatic cancer (PC) is resection followed by adjuvant FOLFIRINOX. We assessed the proportion of patients that managed to complete the 12 courses of adjuvant FOLFIRINOX and compared their outcome with that of patients with borderline resectable pancreatic cancer (BRPC) who underwent resection after neoadjuvant FOLFIRINOX. METHODS: A retrospective analysis was performed on a prospectively maintained database of all PC patients who underwent resection with (2/2015-12/2021) or without (1/2018-12/2021) neoadjuvant therapy. RESULTS: A total of 100 patients underwent upfront resection, and 51 patients with BRPC received neoadjuvant treatment. Only 46 resection patients started adjuvant FOLFIRINOX, and only 23 completed 12 courses. The main reasons for not starting/completing adjuvant therapy were poor tolerance and rapid recurrence. Significantly more patients in the neoadjuvant group received at least six FOLFIRINOX courses (80.4% vs. 31%, p < 0.001). Patients who completed at least 6 courses, either pre- or postoperatively, had better overall survival (p = 0.025) than those who did not. In spite of having more advanced disease, the neoadjuvant group had comparable overall survival (p = 0.062) regardless of the number of treatment courses. CONCLUSION: Only a minority of patients (23%) undergoing upfront pancreatic resection completed the planned 12 courses of FOLFIRINOX. Patients who received neoadjuvant treatment were significantly more likely to receive at least six treatment courses. Patients receiving at least six courses had better overall survival than those who received fewer than six courses, regardless of the timing of treatment relative to surgery. Potential ways to increase chemotherapy adherence, such as administering treatment before surgery, should be considered.

The Use of Inlay Bridge of the Posterior Fascia as Adjuvants to a Modified Rives-Stoppa Repair for Difficult Abdominal Wall Hernias.

BACKGROUND: Major abdominal wall defects remain a highly morbid complication. Occasionally a fascial defect is encountered, that despite all surgical efforts, is unable to completely approximate at the midline. Here we describe our method and outcomes of using a bridging mesh when the posterior fascia was unable to be approximated during the repair of large postoperative ventral hernias using the modified Rives-Stoppa technique. METHODS: A retrospective review was conducted looking at all the open abdominal wall hernia repairs between 2014 and 2020. The cohort of patients who had a bridge placed in addition to the traditional open modified Rives-Stoppa repair were used for this study. RESULTS: Nineteen patients had a mesh inlay bridge placed in addition to a modified Rives-Stoppa repair with a sublay (retrorectus) Ultrapro mesh. For the inlay mesh 13 Symbotex composite meshes were placed and 6 Vicryl meshes used. The average surface area of the defect was 358.1 cm^2. The average length of hospitalization was 8.8 days with a range of 3-24 days. During the immediate postoperative course there were 6 minor complications. During the follow-up period there were 2 recurrences. DISCUSSION: The use of inlay mesh bridge as an adjuvant to a modified Rives-Stoppa repair with a sublay ultrapro mesh is an effective technique for difficult abdominal wall repairs where the posterior fascia is unable to be approximated without tension.

The Impact of the COVID-19 Pandemic on an Israeli Acute Care Surgery Unit: Fewer Patients, More Disease.

BACKGROUND: The COVID-19 pandemic has transformed and affected every aspect of health care. Like any catastrophic event, the stress on hospitals to maintain a certain level of function is immense. Acute surgical pathologies cannot be prevented or curtailed; therefore, it is important to understand patterns and outcomes during catastrophes in order to optimize care and organize the health care system. METHODS: In a single urban tertiary care center, a retrospective study examined the first complete lockdown period of Israel during the COVID-19 pandemic. This was compared to the same time period the previous year. RESULTS: During the pandemic, time to hospitalization was significantly decreased. There was also an overall reduction in surgical admissions yet with a higher percentage being hospitalized for further treatment (69.2% vs 23.5%). The patients admitted during this time had a higher APACHE-II score and Charlson comorbidity index score. During the pandemic, time to surgery was decreased, there were less laparoscopic procedures, and more RBC units were used per patient. There were no differences in overall complications, except when sub-analyzed for major complications (9.7% vs 6.3%). There was no significant difference in overall in-house mortality or morbidity. Length of hospitalization was significantly decreased in the elderly population during the pandemic. CONCLUSION: During the COVID-19 pandemic, despite a significantly less number of patients presenting to the hospital, there was a higher percentage of those admitted needing surgical intervention, and they were overall sicker than the previous year.